Misleading shoulder MRIs lead to unnecessary rotator cuff surgery
See our main page, Prolotherapy for shoulder pain to learn more about our regenerative treatments for shoulder pain. Research can be amazing. In the medical journal The archives of bone and joint surgery, a recent study opened with the following statement:
“Magnetic resonance imaging (MRI) has long been considered a perfect imaging study for evaluation of shoulder pathologies despite occasional discrepancies between MRI reports and arthroscopic findings.”
Did the same thought enter your mind? If it is perfect how can there be discrepancies?
Later in the same study when comparing MRI to arthroscopic evaluation, the same researchers noted:
“…an orthopedic surgeon has the advantage of freely changing the patient’s shoulder posture during arthroscopy to detect a lesion (tear) in contrast to the single static position of the shoulder in the MRI that is reported by radiologists. This may be another source of disagreement.”(1)
In other words, the MRI is taking a snapshot and not providing the whole picture. How then is it perfect?
You are more likely to get a surgery if you had an MRI
In a 2017 study, Doctors at Brigham and Women’s Hospital and the University of Ottawa studied the prevalence of MRI ordering in cases of a shoulder injury. A total of 475 patients who underwent shoulder MRI were included in the study.
The doctors found that:
- patients who had a prior x-ray were more likely to get an MRI.
- patients who got the MRI were more likely to get the surgery
- Orthopedic specialists ordering MRIs had the highest percentage of patients undergo subsequent surgery (33.3%) compared with the second-most, primary care (18.4%).(2)
In this research a path was followed:
- If you had an x-ray you were more likely to get an MRI
- If you had an MRI you were more likely to get a surgery
- If your regular doctor sent you to an MRI you were less likely to get a surgery than if the orthopedist sent you to the MRI
MRIs are frequently used as the basis for determining the need for surgery; however, as with other areas of the body, a shoulder MRI can be very misleading. Some studies have shown that MRIs done on completely asymptomatic individuals show a high prevalence of tears of the rotator cuff.
Questioning what a shoulder MRI says as the basis for rotator cuff surgery is not a new concept, concern reaches the mainstream in 2011
In October 2011, the NY Times reported a fascinating article featuring an interview with well know sports surgeon James Andrews, MD. Seeing that most injured athletes and active people receive MRIs when faced with a sports injury, Dr. Andrews set out to see what MRIs showed on people with no pain or symptoms at all. He performed an MRI on 31 perfectly healthy professional baseball players. The results? 90% showed abnormal shoulder cartilage and 87% showed abnormal rotator cuff cartilage despite a 0% incidence of pain!
The article goes on to cite a few other well-known orthopedists who explain that MRIs are sensitive but not specific and that abnormalities are usually inconsequential. In fact, there are almost never “normal” MRIs. Unfortunately, the use of MRIs has become so common that people believe good and accurate care must involve ordering a fancy test. Many of these doctors cited agree that a proper diagnosis can be made by taking a thorough physical and historical evaluation.
The physical examination is the failsafe to errant MRI observation
An earlier study confirmed what many knew: “Although MRI findings may be diagnostic in some cases, we find that clinical correlation with history and physical examination is critical to differentiate between anatomic variants, incidental findings, and true pathology. We conclude that good communication between the orthopedic surgeon and the radiologist is necessary to optimize diagnostic yield.”3 Clearly, the physical examination is the failsafe to errant MRI observation.
If you have questions about rotator cuff surgery, get help and information from our Caring Medical staff
1. Sefidbakht S, Momenzadeh OR, Dehghani S, Gerami H. MRI-Arthroscopic Correlation in Rotator Cuff Tendon Pathologies; A Comparison between Various Centers. Archives of Bone and Joint Surgery. 2016;4(2):141-144. [Google Scholar]
2. Small KM, Rybicki FJ, Miller LR, Daniels SD, Higgins LD. MRI Before Radiography for Patients With New Shoulder Conditions. J Am Coll Radiol. 2017 Apr 20. pii: S1546-1440(17)30214-4. doi: 10.1016/j.jacr.2017.02.031. [Google Scholar]
3. Bencardino JT, Beltran LS. Pain related to rotator cuff abnormalities: MRI findings without clinical significance. J Magn Reson Imaging. 2010 Jun;31(6):1286-99. [Google Scholar]